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Manic; now have anxiety attacks


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Hi,

I thought I would break this out into a separate post:

Due to bupropion, I'm now having anxiety attacks whenever I do anything (I'm pretty certain it's the bupropion-- I haven't had anxiety in over 10 years). It also has made me manic which could take many months to calm down.

I'm on lithium to stabilize with benzos whenever needed.

Question: what do I do about the anxiety attacks? Can I take a low dose SSRI to permanently squash it now?

Or do I have to wait for the mania to resolve first?

Because I'd rather take care of the anxiety attacks right now, then completely come down from the mania relaxed.

Then that would conclude everything.

Thanks.

 

Edited by ChunkOfCheesecake
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3 hours ago, ChunkOfCheesecake said:

Hi,

I thought I would break this out into a separate post:

Due to bupropion, I'm now having anxiety attacks whenever I do anything (I'm pretty certain it's the bupropion-- I haven't had anxiety in over 10 years). It also has made me manic which could take many months to calm down.

I'm on lithium to stabilize with benzos whenever needed.

Question: what do I do about the anxiety attacks? Can I take a low dose SSRI to permanently squash it now?

Or do I have to wait for the mania to resolve first?

Because I'd rather take care of the anxiety attacks right now, then completely come down from the mania relaxed.

Then that would conclude everything.

Thanks.

 

Personally I’d think adding an antidepressant during mania is a case of risks wayyy outweighing benefits. In BP antidepressants can instigate mania on their own, which means that the SSRI might just make things worse. 
 

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27 minutes ago, Iceberg said:

Personally I’d think adding an antidepressant during mania is a case of risks wayyy outweighing benefits. In BP antidepressants can instigate mania on their own, which means that the SSRI might just make things worse. 
 

I agree-- I was hoping the stabilizer and benzos on hand would be enough to power through using a low dose SSRI.

I really didn't want to play with SSRIs after I'm settled back in, way down the road. Then go through their own disruption of taking them.

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On 10/29/2021 at 12:30 PM, Iceberg said:

Personally I’d think adding an antidepressant during mania is a case of risks wayyy outweighing benefits. In BP antidepressants can instigate mania on their own, which means that the SSRI might just make things worse. 
 

Well I asked a pdoc about taking an antidepressant-- and to no surprise he said: let's wait.

I told him I'm concerned about taking one and I only want to take it in very tiny doses and see how it goes. He seemed to be encouraged by this. Next month we revisit.

Another problem along with the anxiety, is that I've taken on a more serious disposition. I feel edgy; unhappy. I don't have that warm free comfortable happy feeling anymore.  To me that says I need serotonin (which makes sense given what has happened).

This whole situation is surreal.

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1 hour ago, ChunkOfCheesecake said:

Well I asked a pdoc about taking an antidepressant-- and to no surprise he said: let's wait.

I told him I'm concerned about taking one and I only want to take it in very tiny doses and see how it goes. He seemed to be encouraged by this. Next month we revisit.

Another problem along with the anxiety, is that I've taken on a more serious disposition. I feel edgy; unhappy. I don't have that warm free comfortable happy feeling anymore.  To me that says I need serotonin (which makes sense given what has happened).

This whole situation is surreal.

Have you ever tried non antidepressant treatments for bipolar depression (Vraylar, latuda, olanzipine+fluoxetine, seroquel are approved and rexulti, abilify and lamictal are also common) 

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1 hour ago, ChunkOfCheesecake said:

Well I asked a pdoc about taking an antidepressant-- and to no surprise he said: let's wait.

I told him I'm concerned about taking one and I only want to take it in very tiny doses and see how it goes. He seemed to be encouraged by this. Next month we revisit.

Another problem along with the anxiety, is that I've taken on a more serious disposition. I feel edgy; unhappy. I don't have that warm free comfortable happy feeling anymore.  To me that says I need serotonin (which makes sense given what has happened).

This whole situation is surreal.

While adding an SSRI is a classic treatment there has been lots of more recent evidence that they are much less effective in BP than in unipolar depression. Obviously if they’ve already helped you that’s probably different, but a lot of pdocs are also considering non-AD options as first line 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146170/

https://www.psychiatrictimes.com/view/case-against-antidepressants-bipolar-depression-findings-step-bd

There are of course studies saying that SSRIs are a good option, so it’s a blurry picture as most BP med issues are, but I just thought I’d put a couple here. Again, it sounds like the SSRI route has worked for you in the past which probably changes things 

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15 hours ago, Iceberg said:

While adding an SSRI is a classic treatment there has been lots of more recent evidence that they are much less effective in BP than in unipolar depression. Obviously if they’ve already helped you that’s probably different, but a lot of pdocs are also considering non-AD options as first line 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146170/

https://www.psychiatrictimes.com/view/case-against-antidepressants-bipolar-depression-findings-step-bd

There are of course studies saying that SSRIs are a good option, so it’s a blurry picture as most BP med issues are, but I just thought I’d put a couple here. Again, it sounds like the SSRI route has worked for you in the past which probably changes things 

Thanks for those links.

I should be clear, the SSRI (in 2007), did clear out the anxiety and edgy uptight joyless disposition. I believe I had both unipolar and BP depression. The SSRI resolved the unipolar straight away, but it aggravated the BP depression monumentally.

I was a mess for a long time (because I had no meds-- I had no pdoc, I didnt even know what was happening). Cognition, behaviors, and memory were affected.

But after things calmed down (which took a long time) I felt impossibly relaxed and free; I wasnt afraid of anything anymore almost.

So yes an SSRI worked for anxiety (which is what I need now, again), but it was a messy process and recovery.

(I'm worried most about the effect on cognition.)

 

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16 hours ago, Iceberg said:

Have you ever tried non antidepressant treatments for bipolar depression (Vraylar, latuda, olanzipine+fluoxetine, seroquel are approved and rexulti, abilify and lamictal are also common) 

No I havent, I've only used xanax, and now, low dose lithium. I would take the xanax as needed to calm down; it would also resolve the depression temporarily.

I asked for lamictal once, but decided not to take it. (That list you provided looks interesting.)

Usually my BP depression eventually fades away on it's own. It can take a while though, especially after a big issue occurs.

 

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  • 2 weeks later...
On 11/3/2021 at 8:34 AM, ChunkOfCheesecake said:

I believe I had both unipolar and BP depression.

A person cannot be diagnosed with both unipolar depression and bipolar depression. If you experience mania at any point, your depression is, by definition, the bipolar variety. You may have suffered a major depressive episode, but this would have been a feature of either a Bipolar-I or Bipolar-II condition rather than that experienced with Unipolar. This distinction is important because it has implications on the choice of effective medications available to you. Treatment of Bipolar depression with antidepressants, especially in the absence of a co-prescribed mood stabilizer (eg, lithium or divalproex), risks destabilizing the patient’s mood into a manic state, a manic state with mixed features, or a depressive state with mixed features. For more on this, check out this article from the Psychiatric Times.

You mention in other posts that you have had experience with both Effexor and bupropion. Neither of these is an SSRI - Effexor is an MRI, affecting serotonin at low dosages, norepinephrine at mid-range dosages, and dopamine at high dosages; and bupropion is a SNRI, principally affecting norepinephrine. Have you ever taken an actual SSRI, for instance Prozac, Zoloft, Paxil? What was your Effexor dosage? If it was more than 150mg, it probably wasn’t targeting your serotonin.

In any case, it’s fairly clear why your doctor is hesitant to prescribe an SSRI for you - given your BP diagnosis, an SSRI can be expected to aggravate your mania and/or unbalance your mood states unless you add a mood stabilizer along with it.

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4 hours ago, Cerberus said:

A person cannot be diagnosed with both unipolar depression and bipolar depression. If you experience mania at any point, your depression is, by definition, the bipolar variety. You may have suffered a major depressive episode, but this would have been a feature of either a Bipolar-I or Bipolar-II condition rather than that experienced with Unipolar. This distinction is important because it has implications on the choice of effective medications available to you.

Thanks-- I had mentioned unipolar because I had a distinct low mood (a little sad), with low energy (I just wanted to lay around) in combination with constant anxiety. After treatment with Effexor I never felt that way again. But, I then had a new feeling of extremely intense depression with ideation, and very uncomfortable high energy (it was bad) -- i.e. a shift to bipolar depression.

Agreed, following treatment for BP depression has to be the main focus.

 

4 hours ago, Cerberus said:

You mention in other posts that you have had experience with both Effexor and bupropion. Neither of these is an SSRI - Effexor is an MRI, affecting serotonin at low dosages, norepinephrine at mid-range dosages, and dopamine at high dosages; and bupropion is a SNRI, principally affecting norepinephrine. Have you ever taken an actual SSRI, for instance Prozac, Zoloft, Paxil? What was your Effexor dosage? If it was more than 150mg, it probably wasn’t targeting your serotonin.

For Effexor, it was 37.5mg only-- nothing higher.  Also, I have not taken an SSRI.

 

4 hours ago, Cerberus said:

In any case, it’s fairly clear why your doctor is hesitant to prescribe an SSRI for you - given your BP diagnosis, an SSRI can be expected to aggravate your mania and/or unbalance your mood states unless you add a mood stabilizer along with it.

Is lithium sufficient as a stabilizer in this case?

 

Edited by ChunkOfCheesecake
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2 hours ago, ChunkOfCheesecake said:

lithium sufficient as a stabilizer in this case?

theoretically it could be but that's no guarantee. it also depends on dose. did you say you were on 150/day? lithium dosing is typically dictated with blood levels (somewhere between .6 to 1.2 depending on who you ask) so you would probably have to be near that threshold to get the full effect for mood stabilization. Also, like I said above i'm not sure that adding an ssri in the presence of manic symptoms is really going to be a calming effect 

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You would not have had a "shift" to Bipolar Depression - you would have had Bipolar Depression all along. Though you don't specify which type of Bipolar you've been diagnosed with, the depressed state you describe sounds most consistent with Bipolar II. The anxiety is not a feature of your Bipolar disorder, but rather a comorbidity, a separate condition that occurs alongside the Bipolar, and in the case of Bipolar, may complicate treatment. Studies have shown that roughly half of all persons with Bipolar Disorder will also have an anxiety disorder, and a third of them will be symptomatic with it at any time. This article from the National Institutes of Health discusses comorbid anxiety and Bipolar Disorder.

A dose of 37.5mg is the starter dose of Effexor, and the therapeutic range for serotonin, so in theory it would have acted as an SSRI, but the mechanism of its action may not have been the same as a straight-up SSRI for a person with BP. I'm not a pharmacologist, so I don't know if Effexor is considered less risky for use in patients with BP or not. Also for that reason, I wouldn't speculate on whether lithium is a suitable stabilizer for your case. Please realize that no one here is qualified to tell you what you should be taking; we can only tell you what we take and whether it's working for us individually. As @Iceberg is careful to point out above, we can make educated guesses about the efficacy of medications, but there's never a guarantee - your mileage may vary. Each of our brain chemistries is unique, and the treatment that works for one person may not work for another. Please bear this in mind as you consider responses to your inquiry. Your best course is to learn everything you can about Bipolar and the various treatment options available so you can take that knowledge to your next conversation with your care provider.

 

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28 minutes ago, Iceberg said:

theoretically it could be but that's no guarantee. it also depends on dose. did you say you were on 150/day? lithium dosing is typically dictated with blood levels (somewhere between .6 to 1.2 depending on who you ask) so you would probably have to be near that threshold to get the full effect for mood stabilization. Also, like I said above i'm not sure that adding an ssri in the presence of manic symptoms is really going to be a calming effect 

Yes I was doubting if it would work-- I'm on 150mg twice a day. My levels are definitely lower than that range.

True, taking an SSRI will initially have the opposite effect; be very uncomfortable, or worse. Then afterward, eventually, the deep calm settles in (it's what happened last time).

Btw, I feel better-- but I still feel intense, hyperfocused, uptight, more self-important. Yuck.

So far, it looks like this disposition is here to stay, if nothing is done.

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31 minutes ago, Iceberg said:

curious- has your doctor indicated they think the ssri will be as effective as you believe it will?

I told him about the anxiety attacks-- after that, he seemed open to trying later down the road (luckily, for now, the anxiety hasn't shown up; though it came close a few times).

Overall, yes it's way risky.  I'm going back and forth on this.  It stinks losing your super relaxed disposition; that's what I'm struggling with.

 

 

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  • 2 weeks later...

@Cerberus, Thanks for the information.

As for Effexor, it's supposed to have a tendency to be very activating (at least from what I read). Effexor was certainly thorough and activating for me; but mellowed me out.

(The next research project is to see if it's possible to microdose an SNRI/SSRI over time to achieve anxiolytic effects; and to avoid major side effects, or a major snafu.)

 

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3 hours ago, ChunkOfCheesecake said:

As for Effexor, it's supposed to have a tendency to be very activating

I’ve always wondered what people mean when they say a med is ‘activating’. If it means ‘stirs me enough to actually lift me out of the bed’, then I can see it, but otherwise I’ve never had a med that consistently perked me up moodily. But I’m a treatment-resistant double-depressive, and almost nothing lays a glove on me.

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2 hours ago, Cerberus said:

I’ve always wondered what people mean when they say a med is ‘activating’.

In my head I feel like “activating” is more of a physiological descriptor than a mood-related result. As in the med gives me more energy or less need for sleep or the ability to do more things - but these changes aren’t necessary helpful to my mood or overall condition. I found wellbutrin to be very activating - I was super wound up and started pacing all over because I didn’t want to sit down - so the net effect was negative. On the other hand, adderall gives me more energy and more focus but these effects aren’t intrusive so the activation is a positive... so personally I consider activation it’s own thing rather than a specific beneficial effect... at least that’s how my brain processes. 
 

Cerberus I would say that I have also never taken a med (except maybe ketamine) where activation consistently translates to “wow don’t I just feel great today!” Actually if that happened I’d probably be worried 

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4 hours ago, Iceberg said:

I found wellbutrin to be very activating - I was super wound up and started pacing all over because I didn’t want to sit down - so the net effect was negative.

That's similar to my first experience of Wellbutrin, though I described it as making me 'wiggy'.  I take it now, however, and have none of that effect. No idea why, unless it has something to do with taking it in conjunction with Adderall.

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